In case of emergency when health and safety is compromised, please call 911 or 925.424.1699.
Use this form to refer a student to the BIRT Team for assistance and referral. Please submit this form and any
attachments to the Las Positas College Office of Campus Safety & Security electronically or in person.
Student Information
Name: _____________________________________ Student ID Number: ________________________
Incident Information
Date: ________________________________________ Time:____________________________________
Location: ______________________________________________________________________________
Reporting Party Information
Name: ______________________________________ Title/Department: __________________________
Phone: ______________________________________ Email: ___________________________________
Additional Parties Involved: ________________________________________________________________
Additional Parties Emails: __________________________________________________________________
Reporting Party Signature: _______________________________________ Date:_____________________
Please indicate if any behaviors listed below as Student Self Report (SSR) or Staff Observation (SO).
____ Agitation/Restlessness ____ Fatigue/Lack of Energy ____ Personal Hygiene
____ Alcohol/Substance Use ____ High Risk/Risky Behavior ____ Physical Violence
____ Aggression Towards Others ____ Hopelessness/Worthlessness ____ Poor Concentration
____ Change in Attendance ____ Irritable/Angry/Short Tempered ____ Sad/Empty Mood
____ Change in Behavior ____ Loss of Interest/Pleasure ____ Suicidal Thoughts
____ Change in Grades ____ Persistent Sadness ____ Weight Gain/Loss
____ Communicating Threats ____ Persistent Worry ____ Withdrawal/Isolation
____ Other: ____________________________________________________________________________
